Maternity Services
A local guide to
routine antenatal care
for healthy pregnant women
and referral guidance
for assessed risk in pregnancy
Introduction
This ‘aide memoir’ is produced as an additional resource to the ‘Pathways for Maternity Care’
national guidance document produced by NHS Quality Improvement Scotland (March 2009). It is
designed to enhance the referral process when risk assessment indicates a deviation from
accepted normal parameters.
Continuous risk assessment, clear communication and documentation, promoting normality and
supporting women’s choice are key to ensuring best midwifery practice. When a woman’s choice
differs from the recommended care pathway, her choice should be supported in conjunction with a
Supervisor of Midwives and clearly documented in her pregnancy records. The on call Supervisor
of Midwives is available 24 hours via Labour Ward: 01896 826897
The content is not exhaustive and accountability for appropriate referral rests with the midwife
whose knowledge and competence govern her clinical judgement (NMC Midwives Rules 2004,
NMC The Code 2009).
Any additional discussion between Midwife and Obstetrician should be documented on the ‘Record
of Discussion’ sheet, and filed as indicated on the form.
Antenatal Referral Guidance
SCHEDULE OF MIDWIFERY LED CARE FOR
LOW RISK ANTENATAL WOMEN www.nhshealthquality.org
Notes:
A - Height of uterus, blood pressure, urinalysis, oedema, fetal heartbeat and movement,
and emotional wellbeing
B - Fetal growth, presenting part, fetal lie / position, fifths palpable
Shared Care between Midwife and Consultant
Booking History and Maternal Health
Prolonged sub-fertility
IVF/ ICSI / Egg donation
Previous ectopic
Refer to obstetrician
Early ultrasound scan
Early scan at 5+ or 6 weeks
Previous miscarriage
Bicornuate uterus or septum
Maternal Age <16 yrs &
> 40 yrs (prims & parous)
Early scan at 7 - 8 weeks
Refer to obstetrician
Discuss or refer to obstetrician.
Also, if:
<16 yrs: offer Sure Start referral
>38 yrs: offer CUB screening
>40 yrs: offer early USS and CUB screening
Offer Sure Start referral
Consider referral to Dr R Campbell
Fetal Detailed Scan up to 22 weeks
Current or past mental illness
Late Booker > 20 weeks
Drugs history
Concerns re social
or domestic situation
BMI < 18
BMI > 40
Discuss with obstetrician if patient on
- Unusual or complex drug therapy
- Unlicensed medicines or herbal medicine
Sure Start Referral
Consider Child protection pathways
Lifestyle assessment
Growth scan 28 and 34 weeks
Folic Acid 5mg/day
Start care pathway (separate sheet)
Past Obstetric History
3 or more consecutive
miscarriages
Previous small
baby,<2.5kg at term
Previous Caesarean
Section
Previous traumatic
delivery
Previous 3rd degree tear
Previous Shoulder
Dystocia
Previous cholestasis
Early ultrasound scan
Refer to obstetrician
Growth scans 28 and 34 weeks,
earlier if indicated
Refer if concerns about growth,
liquor or Doppler
Refer to obstetrician
Refer to obstetrician
Refer to obstetrician
Refer to obstetrician
If becomes symptomatic, check LFTs and Bile acids. If raised,
refer to ANC.
Gynae History
Previous myomectomy
IUCD in situ
Refer to obstetrician
Refer to on call gynaecology registrar
Previous molar pregnancy
Early USS
Anaesthetic History / related anaesthetic issues
Referral to anaesthetist should be via the obstetrician.
Appropriate indications include:
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Previous or anticipated anaesthetic problems (e.g. failed intubation or regional analgesia,
dural tap, pain during caesarean section)
Severe back or neck problems
BMI > 40
Women who decline blood products
Severe drug reactions
Specific advice at time of midwife booking
Folic Acid (400μg/ until 12 weeks) or 5mg/day if increased risk (previous neural tube
defect or anti-convulsant therapy)
Teratogenic medication (urgent discussion or appointment with obstetrician)
Thyroxine (increase dose by 25μg and check freeT4 and TSH as soon as possible after this)
Ongoing risk assessment throughout pregnancy
Where the following risks are identified in pregnancy, discussion with the on call Obstetric
Registrar or Consultant is appropriate, or an appointment at a Consultant clinic. In more urgent
cases, it may be appropriate to refer directly to Labour Ward or the Pregnancy Assessment Unit.
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Raised blood pressure or symptoms of pre-eclampsia - see page 00
Fundal height or clinical findings suggest small for gestational age - see ANC; if very
small see in PAU
Confirmed exposure to active viral infection when previously non-immune - phone
registrar on call
Malpresentation after 36 weeks – see at ante-natal clinic
Abnormal αFP results or USS – see at PAU
Chlamydia positive - phone registrar on call
Consultant Led Care
Medical disorders in pregnancy
Those with the following medical disorders are suitable to book
at Dr Campbell’s Clinic:
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Epilepsy
Inflammatory Bowel Disease
Coeliac disease
Diabetes
Previous or active thromboembolic disease
Severe Asthma (needing oral steroids or recent hospital admission)
HIV / HEP B / HEP C
Alcohol / Drug Misuse
Heart disease
Major Psychiatric Illness
Renal disease / Liver disease
Severe anaemia / Haematological disease
Connective Tissue / Autoimmune disease / Anti-phospholipids synd
Multiple pregnancy
Those with Twins (or other multiple pregnancy) should have a detailed scan appointment
with Dr Magowan for between 11 – 14 weeks.
For women where the identified risk is through family history,
an appointment with the consultant should be made soon after initial booking.
Significant Hereditary Condition in the family
Known haemoglobinopathy, or known haemoglobinopathy trait and a partner who screens
positive
Past Obstetric History
The following are suitable for consultant led care with whichever consultant is responsible for
that geographical area:
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Previous Mid trimester loss / Previous Cervical suture
Previous stillbirth / neonatal death
Previous haemolytic disease / Rhesus disease
Previous gestational diabetes
Previous congenital abnormality
Significant morbidity of baby
Previous severe PIH / Eclampsia / HELLP
Previous preterm labour
Previous baby AFFECTED by Group B strep
Previous severe / early onset IUGR (<34/40, <1.5kg)
Previous Major Obstetric Haemorrhage (inc abruption)
Where the following risks are identified during ongoing assessment in pregnancy, referral
directly to the Consultant is appropriate:
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Placenta praevia
Preterm rupture of membranes <37 wks
Post term labour >42 weeks
Significant or recurrent APH
Obstetric Cholestasis
Oligo or Polyhydramnios
Haemoglobin < 9g/dl
Platelets <150x109/l, repeat in 4 weeks. If falls to <100x109/l refer to ANC. If very low
(e.g. <80x109/l) refer to on call Reg.
Current active genital herpes
Syphilis, Hepatitis B or HIV positive
Abnormal Oral GTT (fasting >5.4mmol/l, 2 hour >9.0mmol/l)
GENERAL INFECTION ADVICE
Farm workers
Toxoplasma (which causes miscarriage in cows and sheep), a chlamydia (which causes
miscarriage in sheep), and listeria can all cause
miscarriage in humans. Pregnant women should therefore avoid animal work, particularly in the
lambing and calving seasons. Overalls and boots worn for work should be removed at the house
door, and the boots cleaned and left outside. Soiled overalls should be placed directly into the
washing machine by the wearer, who should then wash and dry their hands thoroughly. At the end
of the season the lambing/calving shed should be thoroughly washed and swept out, and left open
to the air for the summer. Handwashing by all who enter the house from the farm at any time is the
key to controlling such infection.
Nurses
Nurses may be concerned about CMV, particularly if they are in contact with small children.
Serology is of little benefit, as the presence of antibodies does not necessarily denote immunity.
Hands should be washed well and often. The risk of CMV is very small.
Travel and vaccinations
Consider aspirin ± graduated compression stockings for long-haul flights. If the woman is visiting
a malarial region, give advice on mosquito nets, wearing long sleeves and trousers (tucked into
socks), insect-repellent spray, cream, wipes, etc. Antimalarials should be taken (Larium should be
avoided if possible, although it may be safe >12 weeks). Refer to GP. The risk of vaccinations is
likely to be extremely small.
Pets
There is a small risk of toxoplasmosis from cats. Women should wear household rubber gloves to
clean litter trays and wash their hands afterwards. Better still, they could get someone else to do it!
They should also avoid children’s sandpits and wear gloves for gardening. Adult dogs with no
diarrhoea do not pose a significant risk.
SPECIFIC INFECTIONS
The risk of chicken pox infection causing harm to the baby in early pregnancy is very small. Give
ZIG (Zoster Immunoglobulin) if < 10 days from contact or < 4 days from onset of rash if the mother
was VZ negative on booking bloods.
Severe and even fatal cases of chickenpox can occur in neonates whose mothers develop
chickenpox from 7 days before to 1 month after delivery (usually 2 days before to 2 days after).
The baby should be given varicella zoster immunoglobulin (VZIG) as soon as possible if maternal
symptoms develop. VZIG may be given to babies in contact with chickenpox whose mothers have
no history of chickenpox (or no antibodies on testing).
Group B β-haemolytic streptococci (GBS)
Antenatal screening is not indicated in the UK (initial screen positives may become negative, and
vice versa). There is no evidence to support antenatal treatment of asymptomatic carriers, as
carriage is rapidly re-established following treatment.
Intrapartum prophylaxis is probably appropriate for:
Those found with GBS on vaginal culture during this pregnancy
Those who have had a previous baby affected by GBS
Those found to have GBS bacteriuria during pregnancy
Prophylaxis is probably not appropriate for:
Those found incidentally to have had GBS in a previous pregnancy, or when not pregnant.
Parvovirus B19
This causes slapped cheek syndrome in children and adults. If a mother develops slapped cheek
syndrome before 20 weeks gestation, the baby can become profoundly anaemic and hydropic.
This anaemia can be treated with intra-uterine transfusions. There is probably no fetal risk beyond
20 weeks. Infection at any stage does not cause fetal abnormality.
If contact significant (with someone who had or has since developed a rash within 48 hrs and was
in face to face contact for > 5 minutes or indoors for >15 minutes) refer to clinic, registrar or PAU
for advice.
Community Monitoring: thresholds for further actions (PRECOG)
Description
Definition
Action by midwife/GP
New
hypertension
without
proteinuria after
20 weeks
Diastolic BP ≥ 90 and <
100mmHg
Diastolic BP ≥ 90 and <
100mmHg with significant
symptoms*
Systolic BP ≥ 160 mmHg
Refer for hospital assessment within 48
hours
Refer for same day hospital assessment
Diastolic BP ≥ 100mmHg
Refer for same day hospital assessment
Diastolic BP ≥ 90mmHg and
new proteinuria ≥ 1+ on
dipstick
Diastolic BP ≥ 110mmHg and
new proteinuria ≥ 1+ on
dipstick
Systolic BP ≥ 170mmHg and
new proteinuria ≥ 1+ on
dipstick
Diastolic BP ≥ 90mmHg and
new proteinuria ≥ 1+ on
dipstick and significant
symptoms
1+ on dipstick
Refer for same day hospital assessment
New
hypertension and
proteinuria after
20 weeks
New proteinuria
without
hypertension
after 20 weeks
2+ or more on dipstick
≥ 1+ on dipstick with significant
symptoms
Refer for same day hospital assessment
Arrange immediate admission
Arrange immediate admission
Arrange immediate admission
Repeat pre-eclampsia assessment in
community within 1 week.
Refer for hospital step-up assessment
within 48 hours
Refer for same day hospital step-up
assessment